Impact of a standardized multi-level review of anti-cancer therapy ordered for hospitalized individuals with solid tumors.

477 Background: Systemic anti-cancer therapy (SACT) administered to hospitalized patients with solid tumors may increase complications and reduce quality of life. We implemented a standardized process to review all non-elective inpatient SACT orders for solid-tumor patients. The goal of the intervention was to improve end-of-life (EOL) care by pausing treatment administration to prompt more cautious consideration of whether treatment risks may outweigh potential benefits. Methods: Our non-elective solid tumor (NEST) review begins with standardized pharmacy and bedside nursing assessments. Treatment proceeds if no concern is identified, otherwise the case is escalated for second physician and/or committee review. For these escalated cases, treatment is only administered after physician review and documentation that the benefit of treatment outweighs potential risks. To evaluate the impact of NEST, we compared two outcomes in the pre-NEST (11/2020 –10/2022) and post-NEST (11/2022-10/2024) time periods. First, we estimated inpatient chemotherapy order rates among hospitalized patients and used Poisson regression to compare across periods. Among decedents, we also calculated the time between SACT order and death, and whether the ordered SACT was ultimately administered; proportions receiving SACT were compared using Fisher’s exact test. Results: In the pre-NEST period, we identified 313 SACT orders among 295 unique hospitalized patients. The post-NEST period included 217 orders among 196 unique hospitalized patients. In the post-NEST period, pharmacy or nursing flagged 90 (41.5%) SACT orders for additional review. The average rate of SACT orders per 100 patient-days was 3.34 ± 1.08 in the pre-NEST period, compared to 2.95 ± 1.00 post-NEST (rate ratio = 0.89; 95% CI: 0.75–1.06; p = 0.20). The proportion of decedents for whom an SACT order was placed was similar during the pre- and post-NEST periods (37.5% vs 43.7% had a SACT order within 30 days of death). However, the proportion of these cases where treatment was ultimately administered was lower post-NEST. Within 7 days of death, treatment was administered in 29.4% of cases post-NEST, compared to 72.7% pre-NEST (p=0.02). This pattern was consistent at longer windows: post-NEST, 43.3% of SACT orders placed within 14 days of death were administered, compared to 67.9% of orders in the pre-NEST (p=0.04) time period. Similar findings were noted during the 30-day interval prior to death (55.7% post-NEST vs 70.2% pre-nest (p=0.01). Conclusions: Although there was no significant difference in SACT order rates, we observed less SACT administration among decedents near EOL following implementation of a multi-level review. This suggests a shift towards more appropriate treatment selection for hospitalized patients with solid tumors following our intervention.